Thoracic spinal epidural hematoma misdiagnosed as conversion paralysis: A case report

Key Clinical Message A woman with a history of psychiatric hospitalization was misdiagnosed with conversion paralysis despite lower extremity paralysis due to a thoracic epidural hematoma, leaving her with severe neurological deficits. Conversion paralysis is a diagnosis of exclusion and should never be made unless all possible organic causes have been ruled out.


| INTRODUCTION
][7][8] Although women are often misdiagnosed with CP, they may have genuine spinal cord lesions. 1In such cases, failure to "diagnose and treat," especially in a timely manner, can result in an irreversible neurological damage that could have been avoided. 1 Therefore, it is very important to keep in mind that a diagnosis of CP should never be made unless all possible organic causes have been ruled out. 8ere we report a case of a woman who developed paralysis of both lower limbs and was misdiagnosed as CP.A few days later, she was diagnosed with thoracic spinal cord epidural hematoma (SCEH) and underwent emergency hematoma removal surgery but remained severely paralyzed.

| Case history and examination
A 48-year-old woman visited the emergency room in the early morning because of sudden-onset muscle weakness in both lower limbs after defecating.She had a history of psychiatric illness (alcohol use disorder) and hospitalizations for said concern but had no history of CP, hypertension, or stroke.The patient had a history of alcoholism and alcohol liver disorder.She was taking anti-alcoholic medication and had not consumed alcohol for the past year.The patient was not on any anticoagulants or antiplatelet medications.
Physical examination revealed bilateral lower extremity muscle weakness (manual muscle test 0-1), hypesthesia, loss of patellar tendon and Achilles tendon reflexes, and negative Babinski reflexes.Blood tests showed no abnormalities in coagulation capacity, platelet count, electrolytes, or liver and kidney function.No imaging studies were performed.The patient was able to maintain a seated position in the clinic.Due to the patient's history of psychiatric visits, this led to a diagnosis of CP.The patient was admitted to the psychiatric hospital where she had been previously admitted.
After 4 days, her paralysis still was not resolved, and she underwent thoracolumbar magnetic resonance imaging (MRI) (Figure 1) at the psychiatric hospital where she was transferred.A diagnosis of spinal cord epidural hematoma (SCEH) and spinal cord degeneration at the thoracic level was made, and the patient was transferred to our hospital.

| Treatment, outcome, and follow-up
Due to the persistent complete motor paralysis and hypesthesia (Frankel B) of the patient below the level examined, she underwent emergent hematoma removal.Unfortunately, the patient's severe paralysis persisted.
MRI on postoperative day 3 confirmed removal of the lesion around T9, which had the most compression on the spinal cord due to the hematoma (Figure 2).
However, the patient's paraplegia did not resolve after the surgery.MRI done at 3 weeks postoperatively showed complete resolution of the hematoma, but there was evident spinal cord degeneration (Figure 3).
One year after surgery, the patient remains paralyzed (Frankel B).

SCEH
The clinical course of spontaneous SCEH often begins with neck or back pain in the case of cervical or thoracic epidural hematoma, respectively, followed by a transition to spinal symptoms. 1,9,10,11Symptoms of SCEH are more likely to appear with activities and states that increase intravascular pressure can cause bleeding, such as pregnancy, exertion, or straining (i.e., Valsalva maneuver). 10,12,13Predisposing factors for SCEH include a history of coagulopathy, use of anticoagulant or antiplatelet medications, hematologic disorders, tumors of the spinal cord, hypertension, and alcoholism. 14,15Interestingly, hemorrhagic spinal complications, including SCEH, have been one of the most common spinal cord lesions caused by SARS-CoV-2 invasion. 16,17Alcoholism and alcoholic liver disorders have been noted to cause hemostatic disturbances, resulting in bleeding from even minor events. 18,19his patient was taking anti-alcoholic medication and did not consume any alcohol for the past year, and blood tests showed no abnormalities in coagulation capacity or liver function; therefore, the effects of alcohol were unknown, although they may have been latent.Poor prognostic factors for SCEH include the onset of pain at the mid and lower thoracic back, use of anticoagulants, loss of sphincter tone, severe neurologic impairment on admission, short progression interval, and spinal cord edema on MRI. 20,21SCEH has a time-sensitive prognosis, with delayed diagnosis potentially leading to permanent neurological sequelae and death.As a rule, emergency hematoma removal is recommended for patients with severe neurologic dysfunction or clinical deterioration. 20,21This patient had a thoracic epidural hematoma that caused sudden-onset motor paralysis of both lower limbs after defecation, followed thereafter by a severe spinal cord injury.Although emergency hematoma removal was warranted, the delay in diagnosis resulted in severe neurological damage.

| Differentiation of CP
This case is a typical example of the pitfalls of mental health bias or mental illness-related stigma,. 24in which physical symptoms are mistakenly attributed to psychiatric causes without conducting a thorough physical examination because the patient had a history of psychiatric illness (alcohol use disorder).
CP remains a diagnosis of exclusion, requiring a systematic and thorough approach.Although electrophysiological diagnostics (motor and somatosensory evoked potentials) and fMRI help clinch the diagnosis, these diagnostics may not be widely available, and cost may be an issue. 8he neurological examination is important in clinical practice.Barre's sign, Hoover's test, and the Spinal Injuries Center (SIC) test are some unique clinical tests that can be done to detect CP. 8,25 Barre's sign places the patient in a prone position, with their knees flexed at right angles.The examiner then releases the support of the knees and instructs the patient to maintain that position; in true paralysis, the affected limb will extend. 8,25In Hoover's test, the patient is in supine position, while the examiner lifts both of the patient's legs slightly off of the exam table. 8,25The patient is asked to lift the affected limb, while the examiner supports both limbs from the heel.If there is no heel downward pressure on the contralateral limb (nonaffected limb), the patient indicates apathy of intent. 8,25owever, Barre's sign and Hoover's test-first reported in 1919 and 1908, respectively-the classic famous clinical tests for the evaluation of hemiplegia are useless for evaluating paraplegia. 8,25he SIC test was designed to evaluate patients with CP and lower extremity motor deficits.The patient lies in a supine position, while the physician passively lifts the patient's knee to the flexed position and places the foot flat on the bed.The physician holds the patient's knees apart.The test is considered positive if the patient can maintain the flexed position. 8By contrast, the patient cannot maintain the knee flexed in severe paralysis, and the paralyzed leg spontaneously falls into flaccid extension.In this case, the SIC test can be considered negative.The SIC test is very simple to conduct and is noninvasive, yet it can make the correct diagnosis of CP (100% sensitivity and 97.9% specificity). 8The SIC test is an examination technique all physicians should be familiar with.It can be useful in making an accurate bedside diagnosis of hysterical paralysis versus a more severe etiology of paralysis.
Despite their profession, medical providers may still hold a "mental health-related stigma" and believe that patients' symptoms are attributable to their psychiatric illness. 24Being aware of these cognitive biases, a diagnosis of CP should never be made unless a systematic and thorough evaluation has ruled out all possible organic causes.

| CONCLUSION
Spontaneous SCEH is a disease for which prompt and accurate diagnosis is crucial; a delay in diagnosis can lead to permanent neurological sequelae.Patients should not be labeled with CP until adequate physical findings and ancillary studies, such as imaging and electrophysiological studies, have ruled out an organic cause.The SIC test is a simple, noninvasive test that can differentiate CP from true/severe paralysis and should be known not only by spine surgeons and neurologists but also by primary care and family physicians.

F I G U R E 1
Magnetic resonance imaging (MRI) before surgery.(A) Sagittal T2-weighted MRI showing spinal cord epidural hematoma at the T8-L1 level, with T9 displaying the area with the most severe spinal cord compression (white arrow) and extensive spinal cord edema.(B) Axial T2-weighted MRI showing significant left-sided spinal cord epidural hematoma at T9 level.

F I G U R E 2
Magnetic resonance imaging (MRI) 3 days after surgery.(A) Sagittal and axial.(B) T2-weighted MRI showing postoperative findings after laminectomy and hematoma removal, and decompression of the thoracic spinal cord.Extensive spinal cord edema (T2 to the conus medullaris) remains.F I G U R E 3 Magnetic resonance imaging (MRI) at 3 weeks after surgery.(A) Sagittal and axial.(B) T2-weighted MRI showing resolution of the hematoma, but there remains an irregular, well-defined hyperintense signal in the T9-11 levels.